A&P of Skin: Changes Across the Lifespan and Dermatologic Terminology
Skin and Wound Care. Produced by the Emory Nursing Wound Ostomy Continence Nursing Education Center.
Transcript
Okay, we're back.
Speaker A:And now we're going to do part two of Skin ap and we're going to focus in this section on changes in the skin across the lifespan, beginning with intrauterine skin development and wound healing, concluding with aging skin.
Speaker A:And then we're going to talk about dermatologic terminology, because those are the terms you should be using when you describe skin lesions and wound status.
Speaker A:So why are we talking about fetal skin and fetal wound healing?
Speaker A:They're not even here yet.
Speaker A:But it's very interesting what we've learned about fetal repair, and it has implications for us in terms of research into wound healing.
Speaker A:So what we've learned is that when surgery is performed late in the second trimester, those wounds heal without scar formation.
Speaker A:Then the question is, why now?
Speaker A:I always think, wow, if you were a surgeon and you did an emergency surgery on a baby late in the second trimester, and then you deliver that baby, and you can see the scar in the mom's abdominal wall, and you can see the scar in the uterine wal, then you deliver the baby and there's no scar, you must be thinking initially, wow, what happened?
Speaker A:Where did that scar go?
Speaker A:So here's what we have learned about healing in the second trimester.
Speaker A:So you know that we now have increased ability to correct some congenital defects by doing surgical correction late in the second trimester.
Speaker A:And so what they do is they provide anesthesia, they go through the uterine wall, they take the baby out, they do the surgery, they put the baby back, close the uterus until the baby's ready for delivery, and those wounds heal without scar.
Speaker A:If we could figure out how it is that those wounds heal without scar, we might be much further along the path in terms of promoting scarless healing among everyone.
Speaker A:So here are the theories so far.
Speaker A:These are theories.
Speaker A:We're not sure that this is the basis for scarless healing, but just interesting to know about.
Speaker A:First of all, we know that there are increased levels of hyaluronic acid in the tissues in babies before they're born.
Speaker A:And what does hyaluronic acid do?
Speaker A:It facilitates cell migration through the tissue.
Speaker A:So you can see that high levels of hyaluronic acid could promote much faster healing.
Speaker A:The other thing that's very different when you talk about wound healing in the fetus is that there's essentially no inflammatory response.
Speaker A:The inflammatory system really hasn't developed yet.
Speaker A:And we know that inflammation is directly associated with scar formation.
Speaker A:So if you intense inflammation, you get a lot more scar.
Speaker A:So it would make sense that if you have essentially no inflammatory response.
Speaker A:It would really damp down scar formation.
Speaker A:We don't know yet, but there's a lot of research on going into fetal repair and the implications for wound management.
Speaker A:I have to tell you a cute story here.
Speaker A:I had a baby and while he was in utero, he was diagnosed with hydrocephalus.
Speaker A:So they're doing the routine ultrasounds and now they see marked enlargement of the ventricles.
Speaker A:And they talk to the mom and dad and they're like, we want to go ahead and we want to put a shunt in so that we don't get any kind of brain damage prior to delivering.
Speaker A:They're like, of course.
Speaker A:So they actually put a shunt in and they, since he was in a sterile environment, they just put the shunt into the ventricle, allowed it to exit just into the amniotic fluid because it was a much simpler procedure and sterile environment.
Speaker A:So they're doing follow up ultrasounds.
Speaker A:Ventricles come down to normal size, everything's looking great.
Speaker A:Two weeks before delivery, they see that the ventricles are starting to enlarge again just slightly.
Speaker A:And then they see he's got the shunt in his hand.
Speaker A:He was okay because delivery was two weeks later.
Speaker A:But his mom said, see, I knew right then he was going to be trouble.
Speaker A:Okay, what about neonates?
Speaker A:So we know that even a normal newborn, their skin is 30% thinner than the skin in an adult.
Speaker A:So that means they're quite vulnerable.
Speaker A:And we know this, we know that newborn skin is very vulnerable, that it's much easier for them to get skin tears to break down from exposure to liquid stool, anything.
Speaker A:Now, on the flip side, we also know babies heal incredibly fast.
Speaker A:Those of you in pediatrics see this all the time.
Speaker A:Those of you who have children have seen this, and that's because they have a much faster epidermal turnover rate.
Speaker A:So normal newborns, yes, there is some increased risk, but they also are much more able to heal their wounds.
Speaker A:Now, we have many more premature babies and a lot of them are less than 30 weeks gestational age.
Speaker A:So what should we know about that patient population?
Speaker A:If you have babies who are born at less than 30 weeks gestational age, you need to know that their skin is extremely thin.
Speaker A:The stratum corneum may only be a few cell layers thick and not really ready to serve as a barrier.
Speaker A:So those babies are going to be high risk for excessive fluid loss, for temperature instability, and of course, for trauma.
Speaker A:And they're not going to heal very quickly because they're so compromised.
Speaker A:Now, at 30 to 32 weeks of gestational age, the stratum corneum is basically formed.
Speaker A:It's essentially normal.
Speaker A:And exposure to air causes rapid maturation of the stratum corneum.
Speaker A:But still it's thinner than in the term baby.
Speaker A:And we want to be careful for any of our premature babies.
Speaker A:So we manage them in temperature controlled, moisture controlled environments.
Speaker A:We're very cautious when we have to secure any kind of device.
Speaker A:We never want to tape directly to the skin.
Speaker A:We're going to come back to that.
Speaker A:We're very, very careful to protect this very fragile skin.
Speaker A:So let's talk about the specific implications.
Speaker A:We've talked a little bit about Morsi, we're going to talk more about it.
Speaker A:Let's talk also about the increased permeability to topical agents.
Speaker A:So when you have a stratum corneum that's only a few cell layers thick, you can see that it's very easy for topical products to penetrate that very thin outer layer and to get into the bloodstream.
Speaker A:That means whenever you're selecting skincare products or wound care products for neonates and premature babies, you have to ask the vendor what testing has been done.
Speaker A:Have you tested these products on term infants?
Speaker A:Have you tested these products on premature infants?
Speaker A:Where's your safety data?
Speaker A:And you don't want to use anything that does not have documented safety for use in that population.
Speaker A:Now, a specific thing you might want to think about is we go back to the trend to use CHG impregnated wipes or CHG isopropyl alcohol for skin prep.
Speaker A:Are those products safe for newborns?
Speaker A:Are those products safe for premature babies?
Speaker A:And we don't have data that says it is.
Speaker A:So you don't want to use those products until that safety data is available to you.
Speaker A:The FDA specifically says that use of CHG isopropyl alcohol prep is contraindicated for use in the premature population.
Speaker A:So you want to make sure that those products are not being used in your agency for that population.
Speaker A:What about medical adhesive related skin injury?
Speaker A:Well, obviously prematures and even newborns are very high risk for medical adhesive related skin injury.
Speaker A:First of all, the skin is thinner, but also you have marked reduction in that interlocking configuration between the epidermis and the dermis because the reed ridges are incompletely formed.
Speaker A:So you don't have a firm connection between the epidermis and the dermis.
Speaker A:And when you take off an adhesive product, it's really easy to take the epidermis off of the dermis.
Speaker A:That means that we should use tapes with extreme caution.
Speaker A:You'll see that when you walk into a nicu, they try to minimize use of tape.
Speaker A:So they'll have non adhesive securement of most devices.
Speaker A:They'll use rap galls to secure IV lines instead of tape, and that is appropriate.
Speaker A:So the guidelines are if you have to secure something to the skin of a neonate or a premature, ideally you would use a silicone based adhesive product.
Speaker A:If it's an absolutely critical device and you don't trust it to a silicone based adhesive, because silicone based adhesives are not as aggressive, then you should first put down a hydrocolloid.
Speaker A:You'll see that under endotracheal tube stabilizers, put down a hydrocolloid, tape to the hydrocolloid, then you can remove tape from the hydrocolloid, leave the hydrocolloid on the skin until it starts lifting on its own.
Speaker A:Another problem that's very common with neonates and especially with the premature babies, is extravasation injuries because they have very small, thin vessels that are very fragile and the sub Q tissue is very distensible.
Speaker A:So it's very easy for lines to penetrate.
Speaker A:The vessels leak out into the sub Q tissue and sometimes there's a delay in recognition because it's not localized swelling, it's generalized swelling.
Speaker A:So the current guidelines are right over the entry site.
Speaker A:Put a transparent dressing so that you can monitor very closely, watch, check every hour, remove promptly.
Speaker A:If there's any evidence of extravasation infiltration, they recommend that you use antidotes if there is an extravasation injury.
Speaker A:Typically we use hyaluronidase injected all the way around the area of infiltration and extravasation, unless it was a vasopressor, a vasoconstrictor, and then you would use phentolamine, regitene.
Speaker A:Now, obviously you're not going to be doing that.
Speaker A:The staff is going to be doing that according to protocols.
Speaker A:So I just wanted to review what the current protocols were.
Speaker A:When you're consulted, it's because they have an entry.
Speaker A:And one of the things that we'll keep coming back to over and over throughout this course is you always do what you can in terms of correcting etiologic factors.
Speaker A:But the pathway to healing is the same for all skin and soft tissue damage, regardless of cause.
Speaker A:The pathway to healing is the same and the basic principles of management remain the same, which is moist wound healing.
Speaker A:So you'll frequently see in NICU's that if there is an extravasation injury with an open wound that they'll be using a gel and sometimes they wrap the foot or the arm in a plastic bag to maintain that moist wound surface.
Speaker A:We'll come back to that.
Speaker A:What about diaper dermatitis?
Speaker A:So here you have a baby with fragile skin, very vulnerable, very ineffective barrier at this point because the stratum corneum is in the process of maturing, in the process of thickening, in the process of becoming really an effective barrier against pathogens and irritants.
Speaker A:And that same skin is exposed to stool and urine multiple times a day and to repetitive cleansing, which can also contribute to the problem.
Speaker A:So the current guidelines are, first of all, do frequent changes and use superabsorbent diapers that wet urine and the liquid components of stool away from the skin.
Speaker A:Be very aggressive in managing any early dermatitis, mild dermatitis, which is evidenced by erythema, but no skin loss.
Speaker A:So with if it's erythema alone, we typically use either a dimethicone based or a petrolatum based barrier to provide additional protection.
Speaker A:If you have actual skin loss, denuded skin now you need to use a zinc oxide product, but you don't want to use plain zinc oxide in general because it's harder to apply, harder to remove, and you can get additional damage.
Speaker A:So most of the time we use zinc oxide plus petrolatum.
Speaker A:So it's a combination product that's easier to apply, easier to remove.
Speaker A:You could also use Ilex, which is very widely used in the pediatric and neonatal population.
Speaker A:And you know, those of you in peds know that Ilex is a topical ointment that contains carboxymethyl cellulose that absorbs moisture.
Speaker A:It contains petrolatum and it contains zinc oxide.
Speaker A:Now, it's not easy to use.
Speaker A:You have to put it on, then you have to coat it with petrolatum and you have to teach people appropriate removal.
Speaker A:But it is very effective for severe denudation.
Speaker A:Okay, so we've talked about your neonatal population.
Speaker A:What about infants?
Speaker A:So these are kids in your picus or, you know, kids admitted to a hospital for a variety of reasons.
Speaker A:The main two issues you're going to face is increased risk of skin tears because they still have incomplete formation of the REIT ridges and so incomplete development of that interlocking configuration.
Speaker A:So we have to be very careful in handling them in starting IVs and doing venous punctures.
Speaker A:And we also have to remember that their head is much larger in relation to their body and so they're going to be pretty high risk for occipital pressure injuries.
Speaker A:What most agencies have found to be most effective, in addition to repositioning the head as tolerated, is to use a gel based pillow that will contour to the head and not cause a doughnut effect.
Speaker A:So we've talked about neonates in infants.
Speaker A:So that part that end of the lifespan, school age children, adolescents, young adults, middle adults, they have pretty healthy skin, they respond pretty well to injury, they heal fairly quickly.
Speaker A:But at the other end of the lifespan, the elderly, there are many, many changes in the skin and the underlying soft tissues that makes them high risk for breakdown and also delays healing.
Speaker A:So we're going to go through the ones that we commonly see and we're going to talk about the ones that are really important in terms of skin health and healing and the ones that are less critical.
Speaker A:So we've talked about the fact that with aging, the rate at which new skin cells are produced is reduced.
Speaker A:So you have fewer skin cells migrating toward the surface.
Speaker A:And over time that creates a thinner outer layer.
Speaker A:So the epidermis thins, that compromises barrier function, makes them more prone to pathogen invasion, to infections, to irritant invasion, which could result in incontinence, associated dermatitis and other irritant responses.
Speaker A:That's significant.
Speaker A:You also get shrinkage of the collagen bundles.
Speaker A:And remember that the dermis is primarily made out of collagen.
Speaker A:So when the collagen bundles in the dermis shrink the epidermis, which is sitting on top, wrinkles.
Speaker A:Now the good thing about wrinkles is they really have no pathologic significance.
Speaker A:They don't increase your risk of breakdown.
Speaker A:The bad thing is they hurt people's feelings, but they don't make them higher risk.
Speaker A:The third thing, and this is significant, is that you start to get breakdown of those reek ridges and that interlocking configuration.
Speaker A:So now instead of all the skin layers moving together, because you've just got epidermis sitting on top of the dermis, if you go to stabilize the skin to start an IV or to do a venipuncture, you may be pulling the epidermis against the dermis.
Speaker A:You're going to see a lot more adhesive related skin damage, a lot more skin tears.
Speaker A:And when you think about patients with skin tears, they're almost always at the extremes of ages.
Speaker A:Either your premature babies and your neonates or it's the elderly.
Speaker A:And that's actually the category in which most of our patients fall.
Speaker A:So we have to be really careful in handling Very careful in use of adhesives, very careful in adhesive removal.
Speaker A:You get drier skin because the sebaceous glands don't work as effectively.
Speaker A:Your ceramide production declines.
Speaker A:So you're not making enough oils to fill the gaps between the skin cells.
Speaker A:So you're going to see dry skin, cracked skin.
Speaker A:It means you have reduced barrier function.
Speaker A:So again, you're higher risk for infections and for irritant responses.
Speaker A:You get increased fragility of the capillaries.
Speaker A:So it's common to look at the extremities of our elderly patients and see purpuric lesions.
Speaker A:So these big areas of purple bruising.
Speaker A:And you might say, what happened?
Speaker A:And they might not even know.
Speaker A:Or they're like, oh, I just bumped into something very common.
Speaker A:There's also a reduction in sensory function because there's some atrophy of the nerve receptors and there's some reduction in neurotransmitter production.
Speaker A:So that means that if I have an elderly patient, maybe they're alert, they're oriented, they're mobile, they have their heels on the bed.
Speaker A:They might not recognize that they're developing a heel pressure injury because of that reduced sensory function.
Speaker A:So we're going to have to ramp up our preventive care for the elderly.
Speaker A:A lot of you have cared for patients and they sustained burns from a heating pad because it didn't feel hot to them.
Speaker A:So just being aware that there is a reduction in sensory function just related to the aging process.
Speaker A:Now, if they are also diabetic and they have any degree of neuropathy, you can see that that would significantly increase their risk for trauma that was unrecognized.
Speaker A:So we have to be, number one, much more vigilant in providing preventive care and also in monitoring, checking those heels, turning them over, making sure that there's nothing under them, that nothing's left in the bed, there's no bed trash that could cause an injury.
Speaker A:Many elderly patients lose weight and they lose sub Q tissue, or if they still have it, it's not exactly where it used to be.
Speaker A:So they get some sagging skin and sagging soft tissue.
Speaker A:So they might not have the same level of protection across the bony prominences.
Speaker A:So again, just increasing your preventive vigilance, especially in your patients who are abnormally thin.
Speaker A:Definitely a reduction in immune function.
Speaker A:So we see many more fungal infections in the elderly.
Speaker A:We also see many more malignancies.
Speaker A:So we see more squamous cell carcinomas, more basal cell carcinomas, more malignant melanomas.
Speaker A:Again, vigilance and monitoring and assessing skin and prompt referral to a dermatologist for any lesion.
Speaker A:We see that we don't really know what it is, or we have concerns that it might be malignant.
Speaker A:Finally, in terms of healing, we know that there's a reduction in blood flow to the skin and soft tissues.
Speaker A:With aging, there's increased levels of cellular senescence.
Speaker A:Now, what does that mean?
Speaker A:Senescent cells have lost the ability to reproduce and to carry out critical functions.
Speaker A:So I call these cells retired in place.
Speaker A:So they're kind of like sitting on the porch, rocking, but they're not doing anything.
Speaker A:So if you have a senescent fibroblast, is it contributing at all to collagen production and to wound healing?
Speaker A:No, it's just sitting there.
Speaker A:So, again, areas of research.
Speaker A:What is it that contributes to cellular senescence?
Speaker A:And is there anything that we can do to get cells out of the chair and back into the workplace?
Speaker A:So we know that that's a potential issue, cellular senescence.
Speaker A:There's also evidence that there's increased production of inflammatory mediators that just keep wounds kind of stuck in an inflammatory cycle and keep them from moving on to healing.
Speaker A:All of these things contribute to slower healing and in some cases, to wounds that never heal.
Speaker A:So we just have to be aware that when we're managing wounds in the elderly, we're fighting an uphill battle.
Speaker A:What about patients in their 90s?
Speaker A:What about patients over 100?
Speaker A:We know those wounds are going to heal slowly, and if there are multiple comorbidities, they may not heal at all with our current level of knowledge.
Speaker A:But again, research is ongoing.
Speaker A:Are these obstacles that can be overcome?
Speaker A:Okay, the last thing we're going to do in this section is we're going to talk about dermatologic terminology.
Speaker A:Now, when you're documenting on a lesion or on the status of a wound, you want to use official terminology so you sound intelligent and professional and so that other practitioners know exactly what it is you're seeing.
Speaker A:So we're going to talk about the terms you're most likely to need to use.
Speaker A:And the first is the terms macule and patch.
Speaker A:Now, macules and patches represent areas of discoloration.
Speaker A:There's no elevation, though.
Speaker A:These are flat areas of the skin where there's discoloration very clearly.
Speaker A:Demarcated macule is a small area less than 0.5 cm in diameter.
Speaker A:And the best example is a freckle.
Speaker A:So a freckle is a macule.
Speaker A:We never call it a macule, but that's what it is.
Speaker A:A patch is more than 0.5 cm in diameter, so this would be like a birthmark.
Speaker A:So if you see on top, you see a patient with a fungal rash.
Speaker A:And fungal rashes are usually characterized by distinct little macules or flat areas of color change.
Speaker A:There might also be patch formation.
Speaker A:So you might have a central area of patch formation, discoloration, and then you might have peripheral lesions that are best described as macules because they're very well defined, there's a color change, and they're flying flat.
Speaker A:So many times we'll talk about a yeast rash, a fungal rash, as being maculopapular with central patch formation.
Speaker A:So what's a papule?
Speaker A:A papule is an elevated lesion.
Speaker A:So it's like a bump.
Speaker A:So macules are like spots and papules are like bumps.
Speaker A:But obviously it's much more.
Speaker A:It sounds much more professional to describe a rash as maculopapular than to describe it as spots and bumps, even though both are accurate.
Speaker A:Okay, so papule is a small elevated lesion.
Speaker A:A bump, a plaque is an elevated lesion that is greater than 0.5 cm in diameter.
Speaker A:So, like our patients with psoriasis frequently have plaque formation, and we recognize that term plaque formation.
Speaker A:In relation to psoriasis.
Speaker A:You're most likely to use the terms macule, papule, plaque and patch in description of yeast rashes, fungal rashes, because they usually are a combination of macules and papules with central patch or plaque formation.
Speaker A:Vesicle and bulla.
Speaker A:So vesicle is a small fluid filled blister, bulla is a large fluid filled blister.
Speaker A:So less than 0.5, greater than 0.5.
Speaker A:And many times when we're taking care of patients with either herpetic lesions, those will be vesicular.
Speaker A:If we have patients who have severe allergic reactions like Stevens Johnson syndrome, there might be a combination of vesicles and bulla.
Speaker A:So these are terms you will definitely be using.
Speaker A:Pustule and abscess.
Speaker A:So pustule is like a pimple or a zit.
Speaker A:It's less than 0.5cm in diameter.
Speaker A:It is an elevated lesion, but it is filled with purulent fluid.
Speaker A:So you can clearly see that as a pustule and not a vesicle.
Speaker A:Abscess is more than 0.5cm and it involves the underlying soft tissue.
Speaker A:So typically what we see at the surface are erythema in duration, possibly fluctuance.
Speaker A:We as wound care nurses don't diagnose abscesses because we can't see to the underlying tissue.
Speaker A:Typically, an abscess is identified when a surgeon comes in, does a clinical assessment, does an incision and drainage.
Speaker A:Once you drain the area and you have the purulent fluid, then it's clear that there was an abscess there.
Speaker A:So we take care of patients.
Speaker A:Status post IND of abscesses.
Speaker A:We don't typically diagnose abscesses.
Speaker A:Denuded and denudation, these are terms you will use almost every day.
Speaker A:In practice, this means superficial skin loss.
Speaker A:It can be patchy, it can be extensive.
Speaker A:So we see this around stomas.
Speaker A:We see it in the perineal area.
Speaker A:In a patient with incontinence associated dermatitis, we frequently see patchy areas of denudation around an open wound caused either by exposure to the wound drainage or by adhesive damage.
Speaker A:So you want to be very familiar with these terms because they are everyday terms for wound care nurses.
Speaker A:And I just want to point out a lot of times people use the term excoriated or excoriation to refer to patchy areas of skin loss.
Speaker A:But officially, excoriated and excoriation refers to linear areas of breakdown caused by scratching.
Speaker A:So you do not want to misuse the terms excoriated and excoriation.
Speaker A:You want to probably take them out of your everyday vocabulary and replace them with denuded and denudation.
Speaker A:Erythema, erythematous, of course, the official terminology for red, so generalized redness, we see this a lot.
Speaker A:We see it in patients with cellulitis.
Speaker A:We see it in patients with any kind of dermatitis, incontinence, associated dermatitis, contact dermatitis, whatever.
Speaker A:So you could say red and raw and it would be accurate, but it would be better to say erythematous with patchy areas of denudation.
Speaker A:So denuded denudation, erythema, erythematous terms you will use all the time, scale versus crust.
Speaker A:So we see scaling and crusting a lot, especially in lower extremity wounds.
Speaker A:So scales are like fish scales.
Speaker A:They're loose fragments of skin.
Speaker A:And it's very common to see, as you see on the top, to see a lot of scaly skin in patients with venous disease and venous ulcers, and in patients with lymphedema.
Speaker A:Crust is different.
Speaker A:Crust is dried exudate.
Speaker A:So crust is the official term for what you probably know as a scab.
Speaker A:So when you get dried exudate on the surface of a wound, that is a crust as opposed to a scab.
Speaker A:It's the official word, erosion versus ulcer.
Speaker A:Erosion typically refers to very superficial skin loss.
Speaker A:We tend to use the term denuded denudation a lot more than eroded or erosion, but either one susceptible ulcer refers in dermatologic terminology to a lesion that extends at least into the dermis, but commonly into deeper tissues.
Speaker A:Typically, ulcers have well defined edges.
Speaker A:We use the term ulcer a lot for lower extremity wounds and for pressure injuries.
Speaker A:Get into that later.
Speaker A:Fischer.
Speaker A:I want you to be very aware of the term Fischer Fissure tells you a lot.
Speaker A:First of all, it refers to a linear crack in the skin surface that extends into the dermis or deeper.
Speaker A:So it's a very accurate term to indicate linear wounds commonly seen in areas that are macerated, usually at the base of a folder.
Speaker A:So underneath the pannis, underneath the breast, within the natal cleft.
Speaker A:The important thing about Fisher is that as soon as you recognize that you're looking at a fissure, as soon as you document it as a fissure, it also tells you a lot about wound etiology.
Speaker A:So in the past, a lot of these wounds would have been incorrectly labeled as pressure ulcers or pressure injuries.
Speaker A:But when you see that linear configuration, it tells you it is probably not a pressure related wound.
Speaker A:It is probably a moisture and friction related wound.
Speaker A:So as soon as you're looking at something that you've documented as being 3 by 0.2, you should think twice before you label that as pressure, because bones are not linear.
Speaker A:But cracks in the skin caused by moisture and friction are linear and are appropriate labeled as fissures, which then in turn leads you back to moisture and friction as the etiologic factors.
Speaker A:Hyperpigmentation, very straightforward, darkened areas of the skin.
Speaker A:We see it in two situations.
Speaker A:Number one, when you have a patient undergoing radiation therapy and the melanocytes overproduce pigment in response to the radiation to try to protect the skin.
Speaker A:So that's what you see on top.
Speaker A:We also see it in patients with venous ulcers.
Speaker A:And what happens there is that red blood cells leak out into the skin, break down and leave their pigment behind.
Speaker A:So you might use the term hyperpigmentation when it comes to a venous ulcer.
Speaker A:Usually we use the term hemosiderosis, which you'll hear much more about.
Speaker A:But definitely when you're referring to areas of radiation dermatitis, we use the term hyperpigmentation.
Speaker A:Okay, now let's talk wound terminologies.
Speaker A:So hopefully you'll get to see a lot of granulation tissue.
Speaker A:That means the wound is healing and you're doing a great job.
Speaker A:What is granulation tissue?
Speaker A:It is proliferating tissue.
Speaker A:It's made up of newly synthesized collagen and other connective tissue proteins.
Speaker A:Collagen's the primary one, and also newly formed capillary network.
Speaker A:So granulation tissue has that bumpy, granular configuration because capillary networks form like this, they form like little bumps.
Speaker A:And then collagen's fibers loop over the capillary networks so that bumpy granular surface looks almost berry, like that's characteristic of granulation tissue.
Speaker A:So bright red, bumpy tissue.
Speaker A:You don't want to describe it like that.
Speaker A:You want to describe it as granulation tissue.
Speaker A:Eschar.
Speaker A:I think you all know the term eschar.
Speaker A:So that's dead tissue, avascular tissue.
Speaker A:It's gray, brown or black.
Speaker A:It can be either dry or moist.
Speaker A:It's typically dry.
Speaker A:So eschar in both of these.
Speaker A:And what about slough?
Speaker A:So slough was the term originally used to describe avascular necrotic tissue that was yellow, white, soft, kind of globular, relatively loose.
Speaker A:And it usually represented dead fat.
Speaker A:So in the top two slides, that's dead fat.
Speaker A:And it would appropriately be described as slough.
Speaker A:Now, the term slough can also be used to refer to a recurrent yellow film that sometimes develops over a wound when there are high levels of bacteria on the surface of the wound and when biofilm is beginning to form.
Speaker A:So here's what I would say to you two things.
Speaker A:First of all, precision in terminology is a condition we have not yet reached in wound care.
Speaker A:And at this point in time, slough.
Speaker A:The term slough can be used to describe any yellow tissue in the wing bed.
Speaker A:And what we know is slough can develop because of tissue ischemia and tissue death, or it can result because of high levels of bacteria on the wound surface and bacterial byproducts.
Speaker A:But it's always yellow and it always needs to be removed if you want the wound to progress.
Speaker A:Tunneling and undermining.
Speaker A:So tunneling is an area of tissue destruction that extends from the wound bed along a linear narrow path.
Speaker A:For example, here there's a tunnel at 6:00.
Speaker A: So there might be a tunnel at: Speaker A:It's a very narrow area of tissue destruction, in contrast to undermining, which is the area of tissue destruction that extends underneath the intact skin and soft tissue for a distance, like from 3 to 6 o'clock.
Speaker A:So both of these slides depict undermining the previous one.
Speaker A:Oops, I went the wrong way.
Speaker A:Let me see if I can fix it.
Speaker A:That detects tunneling versus undermining.
Speaker A:Now, critically important to always explore your wound edges so that you identify areas of tunneling.
Speaker A:You identify areas of undermining because those areas have to be addressed.
Speaker A:When you're addressing the wound, you always want to put a little wick into a tunneled area.
Speaker A:You always want to place some dressing into the undermined area so that you pull fluid out of those areas into the wound bed.
Speaker A:So tunneling, undermining, tunneling a narrow area, undermining a broader area.
Speaker A:So in summary, part two of this section on skin anatomy and physiology, we talked about changes in skin across the lifespan and implications for management.
Speaker A:So neonates and infants have much thinner, more permeable skin.
Speaker A:We have to be very gentle in providing skin care and providing care in general.
Speaker A:We have to be very careful in selecting topical products and make sure that they have been shown to be safe for use in that population.
Speaker A:We also have to recognize that as a category, these babies are very high risk for skin tears and medical adhesive related skin injury.
Speaker A:The elderly are our other very high risk population.
Speaker A:We know that their skin is thinner, drier, so much more vulnerable to penetration and to damage.
Speaker A:They're high risk for skin tears because they've lost a lot of that interlocking configuration.
Speaker A:They have many factors that make them higher risk for skin breakdown and also high risk for delayed healing or for failure to heal.
Speaker A:And then we do expect you to know these derm terms, so study them if you're not already from with them.
Speaker A:These are the terms you'll be using to describe skin lesions and wounds.
Speaker A:Thank you very much.
